Care Evaluation Of Mental Disorders Research Articles

Polymorphic variation at the serotonin 1-A receptor gene is associated with comorbid depression and generalized anxiety

Serotonin 1-A receptors are key regulators of serotonin activity and their dysregulation might be implicated in the emergence of both major depression (MD) and generalized anxiety disorder (GAD). Previous studies have yielded inconclusive results as to whether the 5-HT1A receptor gene (HTR1A) has a role in the aetiology of MD and no study up to date has analysed this polymorphism on either pure MD or MD comorbid with GAD. In this study, 1059 patients taking part in the PREDICT-Gene study were ascertained for Diagnostic and Statistical Manual of Mental Disorders-IV MD and GAD diagnoses using the Composite International Diagnostic Interview and the Primary Care Evaluation of Mental Disorders questionnaire, respectively. They were also genotyped for the C(-1019)G functional polymorphism at the promoter region of HTR1A gene. Genetic variability at HTR1A was significantly associated with MD [odds ratio (OR) = 1.67; 95% confidence interval (CI) = 1.14-2.44; P = 0.008], although this effect disappeared after adjusting for GAD (OR = 1.43; 95% CI = 0.96-2.14; P = 0.080). Similarly, a crude association between C(-1019)G polymorphism and GAD was found (OR = 2.54; 95% CI = 1.28-4.86; P = 0.003), but these results became no longer significant after adjusting for MD (OR = 1.97; 95% CI = 0.99-3.91; P = 0.050). However, a main effect of HTR1A G(-1019) allele on comorbid MD-GAD was found (OR = 3.41; 95% CI = 1.44-8.05; P = 0.005) and it remained robust and statistically significant after adjusting by sex, age and family history of psychological problems (OR = 2.82; 95% CI = 1.18-6.77; P = 0.020). In our study, the HTR1A C(-1019)G polymorphism was found to be associated to the frequent clinical presentation of comorbid MD and GAD, suggesting a common genetic background for mixed depression and anxiety states. These findings should be considered as preliminary. Future replications in independent samples would be needed to confirm or discard such association.

Gender differences in prevalence of depression among patients receiving palliative care: The role of dependency

Background: in community studies the prevalence of depression is higher in women than men; however, in palliative care settings this relationship is usually less strong, absent or reversed. Aim: to identify reasons for excess depression among men receiving palliative care. Design: cross-sectional study. Setting/participants: we interviewed 300 patients recruited from a large hospice in South East London. Depression was measured using the Primary Care Evaluation of Mental Disorder. Results: the higher prevalence of depression among men was not explained by a higher prevalence of particular types of cancer nor confounding by other covariates. Possible effect modifiers were examined. Depending on others for help with basic tasks (eating, dressing, washing or using the toilet) was a risk factor for depression in men only, with 37.8% of dependent men being depressed compared to 2.4% of similarly affected women (OR = 24.3, 3.1–193.2, p = 0.003). We observed a dose-response effect between the level of dependency and depression in men (p for trend = 0.01). Conclusion: depending on others for help with basic tasks appears to contribute to the burden of depression among men with terminal illness. This gender-specific association may explain why the usual gender differences in depression prevalence are not observed in palliative care.

The Swedish validation of Edinburgh Postnatal Depression Scale (EPDS) during pregnancy

Background: Around 10–15% of women suffer from depressive illness during pregnancy or the first year postpartum. Depression during pregnancy constitutes a risk for prenatal stress and preterm birth. No validated screening instrument for detecting depression during pregnancy was available in Swedish. Aims: We aimed to validate the Edinburgh Postnatal Depression Scale (EPDS) against DSM-IV criteria for depression during pregnancy, establish a reliable cut-off and estimate the correlation between the EPDS and HAD-S (Hospital Anxiety and Depression Scale). Methods: In a population-based community sample of 1175 pregnant women, 918 women (78%) answered questionnaires with the EPDS and HAD-S. In all, 121 were interviewed using the PRIME-MD (Primary Care Evaluation of Mental disorders) for diagnosing depression. Women were interviewed in mean gestational week 13 (range 8–21). For the EPDS, a receiver operating characteristic (ROC) curve was calculated for prediction of depression. Pearson's correlation coefficient was used to investigate the association between EPDS and HAD-S scores. Results: The optimal cut-off score on the EPDS scale for detecting depression was ≥13 (standard error coefficient of 1.09 and c-statistics of 0.84) giving a sensitivity of 77% and specificity of 94%. The EPDS scores correlated strongly with the HAD-S, Pearson's correlation was 0.83 (P < 0.0001). Conclusions: This study confirms that the EPDS is a valid screening instrument for detection of depressive symptoms during pregnancy. The EPDS shows persuasive measuring outcomes with an optimal cut-off at ≥13. Clinical implications: Healthcare for pregnant women should consider screening procedures and follow-up routines for depressive symptoms.

Association Between Generalized Anxiety Disorder and Asthma Morbidity

Generalized anxiety disorder (GAD) is common among people with asthma, but its association with asthma morbidity remains unexplored. This study examined cross-sectional associations between GAD and asthma control, quality of life, and self-efficacy. Seven hundred ninety-four adults with confirmed asthma were recruited from the outpatient clinic of a university hospital. Patients underwent a sociodemographic and medical history interview (to assess health service use and medications), followed by a brief psychiatric interview (Primary Care Evaluation of Mental Disorders) to assess GAD. Patients completed questionnaires assessing asthma control, quality of life, and asthma self-efficacy and underwent spirometry. General linear models and logistic regression were used to assess associations between GAD and asthma morbidity measures, adjusting for covariates. GAD affected 4% of the sample. The analyses revealed significant associations between GAD and worse overall asthma control (β = 0.62, standard error [SE] = 0.18, p < .001), increased bronchodilator use (β = 10.60, SE = 2.64, p < .001), worse asthma quality of life (β = -0.91, SE = 0.23, p < .001), and worse asthma self-efficacy (β = -59.56, SE = 13.59, p < .001) after the adjustment for covariates. Separate sensitivity analyses including major depressive disorder and asthma self-efficacy as additional covariates rendered many of these associations nonsignificant. There were no associations between GAD and emergency visits or hospitalizations. GAD is associated with worse asthma morbidity independent of age, sex, smoking, and asthma severity; however, comorbid major depressive disorder and low asthma self-efficacy may account for many of these associations. Only breathlessness and the frequency of bronchodilator use were uniquely associated with GAD. Future research should examine whether treatment of GAD can affect asthma outcomes.

Anxiety and Depression during Hospital Treatment of Exacerbation of Chronic Obstructive Pulmonary Disease

This study investigated the prevalence, risk factors and rate of recognition of anxiety and depression in 50 patients hospitalized for exacerbation of chronic obstructive pulmonary disease (COPD). Using the Primary Care Evaluation of Mental Disorders questionnaire, 13 patients were identified as having depression, four had anxiety and eight had a combination of the two. Patients with anxiety and/or depression had a significantly higher partial pressure of oxygen and pH, and a lower partial pressure of carbon dioxide, in arterial blood on admission, more severe dyspnoea after a 6-min walk test and less improvement of dyspnoea from admission to discharge than COPD patients without anxiety and/or depression. Two patients were referred to a mental health specialist during their hospitalization, indicating a low rate of recognition. The results suggest that patients with mental disorders are referred and admitted to hospital earlier in the course of a COPD exacerbation due to earlier and more intense perception of dyspnoea.

Trends in health-related quality of life and health service use associated with comorbid diabetes and major depression in South Australia, 1998–2008

To investigate the trends in health-related quality of life and health service use associated with diabetes and/or major depression in South Australia from 1998 to 2008. Data analyzed were from 9,059 persons aged ≥15years who participated in representative surveys of the South Australian population in 1998, 2004 and 2008. Major depression was determined using the mood module of the Primary Care Evaluation of Mental Disorders (PRIME-MD). Diagnosed diabetes and health service use were determined by self-report. Health-related quality of life was assessed using the 36-item Short-Form Health Survey (SF-36) and the 15-item Assessment of Quality of Life (AQoL) instruments. Socio-demographics (including mental health literacy), arthritis, asthma, osteoporosis, and obesity covariates were determined by self-report. Weighted age-standardized and multiple covariate-adjusted means of dependent measures were computed. The prevalence of diabetes only, major depression only, and comorbid diabetes and major depression increased by 3.0 (74%), 2.6 (36%), and 0.4 (53%) percentage points, respectively, from 1998 to 2008. Mean health-related quality of life scores were 9 to 41% lower (worse), and health service use was 49% higher for persons with comorbid diabetes and major depression than for those with diabetes only (all P values <0.05) independent of all covariates, consistently over the 10-year period. If past trends continue, our results suggest that the increased population health and economic burden of comorbid diabetes and major depression could persist over the next decade or so. These trends have important implications for making health policy and resource allocation decisions.

FC21-07 - Trends in health-related quality of life and health service use associated with comorbid diabetes and major depression in South Australia, 1998–2008

PurposeTo investigate trends in health-related quality of life and health service use associated with diabetes and/or major depression in South Australia from 1998 to 2008.MethodsData analyzed were from 9,059 persons aged ≥15 years who participated in representative surveys of the South Australian population in 1998, 2004 and 2008. Major depression was determined using the mood module of the Primary Care Evaluation of Mental Disorders (PRIME-MD). Diagnosed diabetes and health service use was determined by self-report. Health-related quality of life was assessed using the 36-item Short-Form Health Survey (SF-36) and the 15-item Assessment of Quality of Life (AQoL) instruments. Weighted age-standardized and multiple-adjusted means of dependent measures were computed.ResultsThe prevalence of diabetes only, major depression only, and comorbid diabetes and major depression increased by 74%, 36% and 53% from 1998 to 2008. Mean health-related quality of life scores were 9% to 41% lower (worse), and health service use was 49% higher for persons with comorbid diabetes and major depression than for those with diabetes only (all P-values &lt; 0.05), consistently over the 10-year period.ConclusionsIf past trends continue, our results suggest that the population health and economic burden of comorbid diabetes and major depression will grow similarly over the next decade or so. These trends have important implications for making health policy and resource allocation decisions.

P01-469 - Validation of patient health questionnaire in Greek-language sample

Lack of validated measures creates obstacles for psychology research progress. The validation of widely used instruments can facilitate research and clinical work.Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire (PHQ) is a cost-effective and psychometrically sound (Spitzer et al., 1999) instrument which is used for the diagnosis of specific psychiatric disorders according to the established diagnostic criteria. Unfortunately, despite its potential utility, PHQ has not been validated or used with Greek language populations.The aim of this study is to conduct a PHQ validation in 520 Greek native-language participants in Cyprus. Appropriate self-report Greek-language measures were identified based on the convergence between the diagnostic specifications of these measures and PHQ diagnoses. The identified measures and the translated PHQ were used for data collection. Participants’ demographic and health information was also gathered.Currently, the project is in its final stages of data collection, and will be completed by December, 2010. Preliminary results, suggest that a number of PHQ subscales have high internal consistency (e.g. Cronbach's alpha coefficient of .81 on Somatization, .83 on Depression) and correlate moderately with other diagnostic measures used (e.g. depression scale r = .43, p &lt; .001 with BDI-II; panic scale r = .5, p &lt; .001 with PDSQ panic scale).Upon completion of data collection, PHQ factor structure, reliability, validity, sensitivity, and specificity will be further investigated. Item and correlation analysis will be confirmed.Strength and weaknesses of PHQ subscales and the employed validation method will also be discussed.

Comparison of participants and non-participants in a randomized study of prevention of depression in patients with acute coronary syndrome

Background: The prevalence of depression and anxiety in patients after acute coronary syndrome (ACS) is higher than in the general population. In a study on prevention of post-ACS depression, more than half of eligible patients declined participation. Aims: The aim of this study was to evaluate whether symptoms of depression and anxiety in participants and non-participants predicted participation in the study. Methods: This substudy was conducted between May 2005 and April 2007. Patients with ACS, eligible for the study (n=302) were asked four questions on depression and anxiety from the Primary Care Evaluation of Mental Disorders (PRIME-MD) screening questionnaire. Results: The PRIME-MD screening data were available on 232 patients (76.8% of eligible patients). Thirty-eight (35.5%) of 107 participants and 30 (24.0%) of 125 non-participants had a positive screening for depression (NS), and 47 (43.9%) participants and 55 (44%) non-participants were screened positive for anxiety (NS). Non-participants were older (P=0.002), while no significant differences in gender or cardiac diagnosis were found. Conclusions: Symptoms of depression and anxiety were highly prevalent in patients after ACS but did not predict participation in the study of prevention of depression.

The Relationship Between Women’s Mental Health and Domestic Violence in Semirural Areas: A Study in Turkey

The authors examine the relationship between emotional disorders and domestic violence (DV) in 395 women of different ethnicities in Turkey. PRIME MD (Primary Care Evaluation of Mental Disorders) was used for diagnosis. This is a cross-sectional and epidemiological research. showed that the prevalence of emotional disorders, anxiety, and somatoform disorders was 22.8%, 24.8%, and 16.9%, respectively. The mean DV score was 2.98±1.32 over 10.00. DV scores were higher when women did not want to get married or did not have their family's blessing for marriage. Observed scores were also high for civil marriage cases, or when women had a job, had low income, or were afraid of their husbands (P<.05). The number of comorbid diagnoses increased with increase in DV scores (P<.001). Mean DV scores were higher for women diagnosed with major depression, partial remission or recurrence of major depression, panic disorder, and common anxiety (P<.05). The authors recommend that if physicians suspect any emotional disorders in women in primary care, they should evaluate for DV.

Undetected depression in primary healthcare: Occurrence, severity and co-morbidity in a two-stage procedure of opportunistic screening

Background: Depression often remains undetected in primary healthcare, and a two-stage screening procedure has been recommended for future research on the recognition, management and outcome of these patients. The aim of this study was to analyse the occurrence and the severity of depression, as well as gender, age and psychiatric co-morbidity in patients with previously undetected depression using a screening questionnaire followed by a diagnostic interview for detecting depression among patients visiting primary healthcare. Methods: All patients visiting a primary healthcare centre during a period of 10 days were asked to fill in the self-rating version of the Montgomery–Åsberg Depression Rating Scale. Patients with a score of 12 or more were invited to participate in a structured diagnostic interview based on the Primary Care Evaluation of Mental Disorders. Results: Out of 221 (=N) participants, 45 (20.4%) patients showed signs of depression (scores of 12 or more). Of these 45 patients, 31 consented to the structured interview, and of those, 28 (12.7%) fulfilled the criteria for depression, 17 (7.7%) had a major depression and 11 (5.0%) had a mixed depression–anxiety condition. Conclusions: The rate of undetected depression in primary healthcare was considerable. The majority of these patients had a major depression. Psychiatric co-morbidity among depressed patients was almost universal. The two-stage procedure of opportunistic screening with the Montgomery–Åsberg Depression Rating Scale and the Primary Care Evaluation of Mental Disorders seems to be a feasible method for detecting these patients in primary healthcare.

Comorbidity between common mental disorders and chronic somatic diseases in primary care patients

Objective To estimate the prevalence of the most common mental disorders in primary care patients with chronic somatic diseases based on physicians' diagnoses and compared with healthy probands. Method A systematic sample of 7940 adult primary care patients was recruited by 1925 general practitioners (GPs) in a large cross-sectional national epidemiological study. The Primary Care Evaluation of Mental Disorders (PRIME-MD) was used as standardized instrument for the assessment of mental disorders. Medical diagnoses were provided by patient's GP. Results The prevalence rate of mental disorder was significantly higher in patients with chronic somatic diseases (56.8%) compared with physically healthy subjects (48.9%; OR: 1.37). Prevalence of depressive and anxiety disorders is higher among individuals with neurological, oncological or liver disease. The differences are significant in all comparisons, with the exception of anxiety disorders in patients with musculoskeletal disorders. There is an increase in prevalence rates of mental disorders according to the number of somatic diseases. Conclusions The study provides evidence of the comorbidity of common mental disorders and somatic diseases. We need a predominant focus on affective and anxiety disorders in primary care patients with chronic somatic diseases. Symptoms overlap makes it necessary to discriminate these differences more in detail in future studies.

PC-FACS

PC-FACS

Depression during pregnancy in women with a medical disorder: risk factors and perinatal outcomes

BACKGROUND:Approximately one‐fifth of women present depression during pregnancy and puerperium, and almost 13% of pregnant women experience a major depressive disorder.OBJECTIVE:The aim of this study was to identify risk factors for depression among pregnant women with a medical disorder and to evaluate the influence of depression on perinatal outcomes.METHODS:Three hundred and twenty‐six pregnant women with a medical disorder were interviewed. A semistructured interview was conducted for each participant using a questionnaire that had been developed previously. Major depression was diagnosed using the Portuguese version of the Primary Care Evaluation of Mental Disorders (PRIME‐MD). The medical records of the participants were thoroughly reviewed to evaluate the perinatal results.RESULTS:Major depressive disorder was diagnosed in 29 cases (9.0%). The prevalence of major depression was as follows: 7.1% for preeclampsia or chronic hypertension, 12.1% for cardiac disorder, 7.1% for diabetes mellitus, 6.3% for maternal anemia, 8.3% for collagenosis and 12.5% for a high risk of premature delivery. An univariate analysis showed a significant positive correlation between an average household income below minimum wage and a PRIME‐MD diagnosis of major depression. A multiple regression analysis identified unplanned pregnancy as an independent predictor of major depression (86.2% in the group with a diagnosis of major depression by PRIME‐MD vs. 68.4% in the group without major depression). A comparison between women who presented major depression and those who did not revealed no significant differences in the perinatal results (i.e., preterm delivery, birth weight and low Apgar scores).CONCLUSION:In the present study, unplanned pregnancy in women with a medical disorder was identified as a risk factor for major depression during gestation. Major depression during pregnancy in women with a medical disorder should be routinely investigated using specific methods.

Primary Care Evaluation of Mental Disorders (PRIME-MD) Screening for Minor Depressive Disorder in Primary Care

Individuals visiting a primary care practice were screened to determine the prevalence of depressive disorders. The DSM-IV-TR research criteria for minor depressive disorder were used to standardize a definition for subthreshold symptoms. Outpatients waiting to see their physicians at 3 community family medicine sites were invited to complete a demographic survey and the Primary Care Evaluation of Mental Disorders Patient Questionnaire (PRIME-MD PQ). Those who screened positive for depression on the PRIME-MD PQ were administered both the PRIME-MD Clinician Evaluation Guide (CEG) mood module and the Hamilton Depression Rating Scale (HDRS) by telephone. Data were collected over a 2-year period (1996-1998). 1,752 individuals completed the PRIME-MD PQ with 478 (27.3%) scoring positive for depression. Of these 478 patients, 321 received telephone follow-up using the PRIME-MD CEG mood module and the HDRS. PRIME-MD diagnoses were major depressive disorder (n = 85, 26.5%), dysthymia (n = 31, 9.6%), minor depressive disorder (n = 51, 15.9%), and no depression diagnosis (n = 154, 48.0%). The mean HDRS scores by diagnosis were major depressive disorder (20.3), dysthymia (12.9), minor depressive disorder (11.7), and no depression diagnosis (5.8). Post hoc analyses using Dunnett's C test indicated differences between each of the 4 groups at P ≤ .05, with the exception that dysthymia and minor depressive disorder were not significantly different. Minor depressive disorder was more prevalent than dysthymia and had similar symptom severity to dysthymia as measured by the HDRS. More research using standardized definitions and longitudinal studies is needed to clarify the natural course and treatment indications for minor depressive disorder.

Prevalence of depression and anxiety in hospitalized chronic obstructive pulmonary disease patients and their quality of life: a pilot study

AbstractIntroduction: There is a high prevalence of psychiatric comorbidities in patients with Chronic Obstructive Pulmonary Disease (COPD). It has been reported that if left untreated, the psychiatric comobidities can lead to poorer quality of life. The present study was initiated to investigate the prevalence of major depressive disorder, generalized anxiety disorder and panic disorder in hospitalized COPD patients and their quality of life.Methods: The Patient Health Questionnaire (PHQ) of the Primary Care Evaluation of Mental Disorders (PRIME‐MD) was administered to screen an opportunistic sample of COPD patients admitted to a general hospital for the abovementioned psychiatric disorders. The Medical Outcomes Study (MOS) 36‐Item Short Form Health Survey (SF‐36) was utilized to assess quality of life.Results: Fifty‐one patients were analyzed. The prevalence of major depressive disorder in this sample on screening was 7.8% (95% CI 2.2–18.9) and that of anxiety disorders (generalized anxiety disorder and panic disorder) was 5.9% (95% CI 1.2–16.2). The quality of life of COPD patients with psychiatric comorbidities in the present study was severely impaired in seven of the eight domains measured by the SF‐36.Discussion: Despite the small sample size of COPD patients, the prevalence of psychiatric comorbidities was not insignificant. The present study showed that the quality of life of hospitalized COPD patients with psychiatric illnesses was significantly lowered. Treatment of COPD should include addressing psychosocial issues.

Apathy and Functioning in First-Episode Psychosis

Apathy and Functioning in First-Episode Psychosis

Association Between Clinical Depression and Endothelial Function Measured by Forearm Hyperemic Reactivity

To assess associations between clinically significant depression (major depressive disorder [MDD] and minor depressive disorder [MiDD]) and endothelial function (EF), via forearm hyperemic reactivity (FHR), in patients referred for myocardial perfusion imaging. Studies have linked MDD to impaired EF, an early marker of coronary heart disease (CHD) and risk factor for cardiac events, in healthy, noncardiac patients, although no studies have assessed the MDD-EF association in patients with or at risk for CHD. Depression was assessed, using the Primary Care Evaluation of Mental Disorders structured interview in 323 patients (n = 242 men; mean age = 59 years) with or at risk for CHD. FHR was assessed, using a dynamic nuclear imaging technique that measures the dilatory capability of the brachial artery during hyperemic challenge. The relative uptake ratio (RUR) of blood flow between hyperemic and nonhyperemic arms was used to measure FHR. Patients with MDD and MiDD had lower RURs (mean values = 3.31 and 3.34, respectively), indicating poorer EF than patients without depression (mean = 4.27) (F = 5.19, p < .01), irrespective of CHD status. All results were adjusted for covariates including sociodemographic, medical, biochemical, and physiological variables. Patients with clinical levels of depression had worse FHR than patients without depression, irrespective of CHD status and after adjusting for covariates. Data extend previous findings, suggesting that the link between clinical depression and worse CHD outcomes may be mediated by EF.

Violence and depressive symptoms during pregnancy: a primary care study in Brazil

To estimate the prevalence of violence, depressive symptoms, and associated factors during pregnancy in women attending antenatal care in Brazil. Violence was assessed using a modified version of the abuse assessment screen (ASS), and depressive symptoms were evaluated using the primary care evaluation of mental disorders (PRIME-MD). Participants were pregnant women attending 18 primary care units in Rio Grande do Sul, Brazil, between June 2006 and April 2007. A total of 712 pregnant women participated, but only 627 of them responded the ASS. Experience of any lifetime violence was reported by 273 (43.4%) women and 114 (18.2%) reported violence during the current pregnancy. One-third of them (n=211) reported lifetime domestic violence and 100 (15.9%) women reported this type of violence during the current pregnancy. Experience of domestic violence during pregnancy was more common in unemployed women, among those with two or more children, with a higher consumption of alcohol, and who had not planned their current pregnancy. Of the total of sample (n=712), 198 (27.8%) women reported six or more depressive symptoms. The presence of depressive symptoms during pregnancy was associated with low educational levels, living in a household with five or more people, and with higher consumption of alcohol during pregnancy. Pregnant women attending primary care are exposed to high rates of domestic violence, and many have clinically relevant depressive symptoms. Appropriate interventions to avoid or minimize the effects of violence and mental disorders to the well-being of the mothers and their babies are urgently required. Primary care services play an important role in identifying and supporting women at risk.

Medical Students and Depression

In Reply: Dr. Hubbeling highlights the need to make a distinction between depressive diagnoses and their symptoms. The Center for Epidemiologic Studies Depression Scale (CES-D), which she discusses, is an excellent screening measure, assessing depressive symptoms developed in nonclinical populations. While it has been shown to predict major depression and dysthymic disorder, it is not a diagnostic measure. In our medical trainee project, we also administered the Primary Care Evaluation of Mental Disorders (PRIME-MD), a tool based on DSM-IV criteria. We found that 2.8% of medical students and 3.5% of residents met DSM-IV criteria for major depression (data unpublished), substantially fewer than identified as “probable depression” using the CES-D. Because the DSM-IV criteria (as Dr. Hubbeling points out) cast an overly wide net for diagnosing depression, we are all the more encouraged by the PRIME-MD finding, even though the PRIME-MD cannot substitute for a clinical interview. But no matter which screening measure is used, and even though not everyone reporting high levels of symptoms has a diagnosable depressive disorder, those individuals who do report high levels are suffering and may benefit from intervention. Given the symptom rates among medical trainees, we feel it is important to regularly screen for depression and to make mental health resources available. Drs. Dyrbye and Shanafelt also make good points about the need to identify suicidal ideation and to be aware of burnout among medical trainees. Collectively, this emphasizes the importance of students' maintaining their health and well-being in medical school. At our program, these are key domains of the educational program. Our medical student graduates must adopt strategies to cope with the risks, stresses, and forms of impairment encountered in medical training. There are also environmental factors that can improve well-being such as work hours, rotation schedules, and consistency between modeled behavior and trainee expectations. The roots of suicide are multifaceted. Depression is only one potential contributing factor. Physical, emotional, and financial stress; anxiety; burnout; relationship difficulties and the inability to balance personal and professional life; inability to meet patient expectations or deal with patient suffering and death; poor coping skills; and substance misuse are just some of the experiences that may play a stressing role in the lives of medical trainees. We encourage programs to take a comprehensive approach to fostering and promoting well-being among their medical trainees. Deborah Goebert, DrPH Associate professor and associate director of research, Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii; ([email protected]). Junji Takeshita, MD Associate professor and associate chair of clinical services, Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii.